Wolters Kluwer Health
may email you for journal alerts and information, but is committed
to maintaining your privacy and will not share your personal information without
your express consent. For more information, please refer to our Privacy Policy.

Issue Overview

Continuum: Lifelong Learning in Neurology ® is designed to help practicing neurologists stay abreast of advances in the field while simultaneously developing lifelong self-directed learning skills.

Learning Objectives

Upon completion of this Continuum: Lifelong Learning in Neurology Dementia issue, participants will be able to:

▸ Perform a cognitive examination of patients suspected of having a neurodegenerative condition and develop a framework for the clinical evaluation and ancillary testing of patients at risk for a neurodegenerative dementia

▸ Discuss the unifying and differentiating features of dementia with Lewy bodies and Parkinson disease dementia, distinguish these entities from other parkinsonian dementias and Alzheimer disease, and review their current management

▸ Discuss the clinical, neuroimaging, genetic, and pathologic features of frontotemporal dementia and related disorders to aid in the evidence-based diagnosis and management of patients presenting with these conditions

aDr Finger has received personal compensation as a speaker for Western University and receives grant support from the Canadian Institutes of Health Research for this work as well as grant funding from the Alzheimer Society of Canada, the Ministry of Research and Innovation, Ontario Brain Institute, and the Weston Foundation. Dr Finger has provided expert legal testimony for the Ontario Court of Justice.

bDr Finger discusses the unlabeled/investigational use of disease-modifying therapies in development, dopaminergic medications, neuroleptic medications, oxytocin, and selective serotonin reuptake inhibitors for the treatment of frontotemporal dementias as discussed in the article “Frontotemporal Dementias.” In the Patient Management Problem, Dr Finger discusses the unlabeled/investigational use of antipsychotic medications for behavioral management in dementia.

Liana G. Apostolova, MD, MS, FAAN

Professor of Neurology, Radiology, and Medical and Molecular Genetics, Barbara and Peer Baekgaard Professor in Alzheimer’s Disease Research, Indiana University School of Medicine, Indianapolis, Indiana

aDr Apostolova serves as senior associate editor of Alzheimer’s & Dementia: Diagnosis, Assessment & Disease Monitoring and receives personal compensation for serving on the speaker’s bureau of Eli Lilly and Company and GE Healthcare Worldwide. Dr Apostolova receives grant support from the Jim Easton Consortium for Alzheimer’s Drug Discovery and Biomarker Development and the National Institute on Aging.

bDr Apostolova discusses the unlabeled/investigational use of antidepressant and antipsychotic medications for behavioral management as well as antidementia therapy in mild cognitive impairment.

aaDr Cohen has received personal compensation from the American Academy of Neurology for educational speaking engagements, has served as an expert consultant for the Division of Vaccine Compensation and the United States Department of Justice and Health & Human Services, and serves on the speakers bureau of the United Mitochondrial Disease Foundation. Dr Cohen serves on the editorial boards ofMitochondrian and Pediatric Neurology, serves as content editor for Motive Medical Intelligence, and has received personal compensation and travel expenses as a consultant for Stealth BioTherapeutics. Dr Cohen receives research funding from the National Institutes of Health (GG006326-03), and Dr Cohen’s institution has received compensation for his lectures at Courtagen Life Sciences, Inc, and Transgenomic, Inc, and for his expert witness testimony in various court cases. Dr Cohen’s institution has also received research support from Edison Pharmaceuticals, Inc, Raptor Pharmaceuticals, Reata Pharmaceuticals, Inc, and Stealth BioTherapeutics, and Dr Cohen has also received travel expense reimbursement from these entities.

bDr Cohen reports no disclosure.

Peter D. Donofrio, MD, FAAN

Professor of Neurology, Vanderbilt University, Nashville, Tennessee

aDr Donofrio has served on the scientific advisory board of and as a consultant for Baxter, CSL Behring, and UCB, Inc, and has served on the editorial board of Muscle & Nerve.

aDr Gauthier receives personal compensation for serving on the scientific advisory boards of AFFiRiS, Eli Lilly and Company, and Hoffmann-La Roche Ltd; for serving as chair of the scientific advisory board of TauRx Therapeutics; and as a lecturer for Ever Pharma and Schwabe, Williamson & Wyatt. Dr Gauthier serves as an editorial board member of Alzheimer’s & Dementia: The Journal of The Alzheimer’s Association, Current Medical Research & Opinion, Dementia and Geriatric Cognitive Disorders, Eurasian Journal of Medicine, European Neurology, and the World Journal of Biological Psychiatry. Dr Gauthier receives research funding as site principal investigator of the Eli Lilly and Company and Hoffmann-La Roche Ltd, and receives funding for this work from the Canadian Institutes of Health Research and the Canadian Consortium on Neurodegeneration in Aging as chair of the Ethical, Legal, and Social Issues advisory committee. Dr Gauthier receives book royalties from Cambridge University Press.

bDr Gauthier reports no disclosure.

Michael D. Geschwind, MD, PhD

Professor of Neurology, Michael J. Homer Chair in Neurology, Memory and Aging Center, University of California, San Francisco, San Francisco, California

aDr Geschwind serves on the board of directors for San Francisco Bay Area Physicians for Social Responsibility and serves as a consultant for Advance Medical, Best Doctors, Inc, the Franciscan Physician Network, the Gerson Lehrman Group, Inc, Lewis Brisbois Bisgaard & Smith LLP, MEDACorp, and Quest Diagnostics. Dr Geschwind receives personal compensation as a speaker for grand rounds lectures and receives research/grant support from Cure PSP, the Michael J. Homer Family Fund, the National Institute on Aging, Quest Diagnostics, and the Tau Consortium.

aDr Gomperts receives grant support from the National Institutes of Health as principal investigator of study 1-R21-NS-090243-01 and receives research support as principle investigator from the National Parkinson Foundation.

bDr Gomperts reports no disclosure.

Murray Grossman, MD, FAAN

Professor of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania

aDr Grossman receives personal compensation for serving as a consultant for C2N Diagnostics, as a lecturer for the Lundbeck Institute, for serving on the international scientific advisory board of the Max Planck Institutes, and for serving as associate editor of Neurology. Dr Grossman’s institution has received grant support from the National Institutes of Health (AG017586, AG038490, NS044266, and NS053488), and Dr Grossman has received research support from the Arkin Family Foundation, the Samuel I. Newhouse Foundation, Inc, and the Wyncote Foundation.

bDr Grossman reports no disclosure.

David J. Irwin, MD

Assistant Professor of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania

aDr Irwin’s institution receives grant support from the National Institutes of Health and the National Institute of Neurological Disorders and Stroke (K23NS088341-01).

aProfessor Malm receives royalty payments from Likvor AB, where he holds patents related to the CELDA infusion device, which is approved within the European Union, but not in the United States, and receives payments for a patent of a new CSF shunt design created with Medtronic, Inc. Professor Malm receives research support as principal investigator for studies from the Swedish Heart-Lung Foundation and the Swedish National Space Board.

bProfessor Malm reports no disclosure.

Andrew McKeon, MD

Associate Professor of Neurology and Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota

aDr McKeon receives research funding from MedImmune.

bDr McKeon discusses the unlabeled/investigational treatments for autoimmune encephalopathies and dementias, none of which have been approved by the US Food and Drug Administration for these indications.

Chiadi U. Onyike, MD, MHS

Associate Professor of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland

aDr Onyike has received personal compensation as special issue editor for the International Review of Psychiatry and the Psychiatric Clinics of North America and has given expert legal testimony for the Paley Rothman law firm on disabilities related to frontotemporal dementia. Dr Onyike receives research funding from the Jane Tanger Black Fund for Young-Onset Dementia Research, the National Institute of Neurological Disorders and Stroke, the National Institute on Aging, the National Institutes of Health, the Robert and Nancy Hall family, and Tau Therapeutics.

bDr Onyike discusses the unlabeled/investigational indications and evidence for efficacy and risks of prescribing antidepressants, antipsychotics, and other psychotropic agents for treating psychiatric aspects of dementia, as well as the alternatives to making these prescriptions, which include behavioral interventions, care programs, caregiver support and training, environment modulation, and structured recreation

aDr Petersen serves on the board of directors for the Alzheimer’s Association and receives personal compensation for serving as chair of the data monitoring committees for Janssen Alzheimer Immunotherapy and Pfizer Inc. Dr Petersen receives personal compensation as a consultant for Biogen, Eli Lilly and Company, the Federal Trade Commission, Genentech, Inc, Hoffmann la Roche, Inc, and Merck & Company, Inc. Dr Petersen receives grant and funding support from the Mayo Foundation for Education and Research, the National Institute on Aging, and the Patient Centered Outcomes Research Institute (PAT 206548). Dr Petersen receives royalties from Oxford University Press.

aDr Smith serves as a board member of the Quality Oversight Committee of the American Heart Association and as an assistant editor for Stroke. Dr Smith receives grant support from the Alzheimer Society of Canada, the Canadian Institutes of Health Research, the Canadian Partnership Against Cancer, and the Heart and Stroke Foundation of Canada and receives research support from McMaster University.

bDr Smith discusses the unlabeled/investigational use of cholinesterase inhibitors for the treatment of vascular dementia.

Michael A. Williams, MD, FAAN

Professor of Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle, Washington

aDr Williams serves on the technical advisory board for and holds stock options in Aqueduct Critical Care, Inc, and has received personal compensation and travel expenses as a lecturer for Codman Neuro, Canada. Dr Williams has received research support from the National Space Biomedical Research Institute as principle investigator of study SMST02801, comparing the continuous noninvasive and invasive intracranial pressure management therapies, and as co-investigator of study CA02801, investigating the effects of microgravity on intracranial pressure. Dr Williams has received research support from NeuroDx Development for research funded by the National Institutes of Health.

aDr Safdieh receives personal compensation for providing expert legal testimony and for the development of educational presentations from Elsevier.

bDr Safdieh reports no disclosure.

Methods of Participation and Instructions for Use

Continuum: Lifelong Learning in Neurology® is designed to help practicing neurologists stay abreast of advances in the field while simultaneously developing lifelong self-directed learning skills. In Continuum, the process of absorbing, integrating, and applying the material presented is as important as, if not more important than, the material itself.The goals of Continuum include disseminating up-to-date information to the practicing neurologist in a lively, interactive format; fostering self-assessment and lifelong study skills; encouraging critical thinking; and, in the final analysis, strengthening and improving patient care.Each Continuum issue is prepared by distinguished faculty who are acknowledged leaders in their respective fields. Six issues are published annually and are composed of review articles, case-based discussions on ethical and practice issues related to the issue topic, coding information, and comprehensive CME and self-assessment offerings, including a self-assessment pretest, multiple-choice questions with preferred responses, and a patient management problem. For detailed instructions regarding Continuum CME and self-assessment activities, visit aan.com/continuum/cme.The review articles emphasize clinical issues emerging in the field in recent years. Case reports and vignettes are used liberally, as are tables and illustrations. Video material relating to the issue topic accompanies issues when applicable.The text can be reviewed and digested most effectively by establishing a regular schedule of study in the office or at home, either alone or in an interactive group. If subscribers use such regular and perhaps new study habits, Continuum's goal of establishing lifelong learning patterns can be met.

Relationship Disclosure: Dr Cohen has received personal compensation from the American Academy of Neurology for educational speaking engagements, has served as an expert consultant for the Division of Vaccine Compensation and the United States Department of Justice and Health & Human Services, and serves on the speakers bureau of the United Mitochondrial Disease Foundation. Dr Cohen serves on the editorial boards of Mitochondrian and Pediatric Neurology, serves as content editor for Motive Medical Intelligence, and has received personal compensation and travel expenses as a consultant for Stealth BioTherapeutics. Dr Cohen receives research funding from the National Institutes of Health (GG006326-03), and Dr Cohen’s institution has received compensation for his lectures at Courtagen Life Sciences, Inc, and Transgenomic, Inc, and for his expert witness testimony in various court cases. Dr Cohen’s institution has also received research support from Edison Pharmaceuticals, Inc, Raptor Pharmaceuticals, Reata Pharmaceuticals, Inc, and Stealth BioTherapeutics, and Dr Cohen has also received travel expense reimbursement from these entities.

Dr Donofrio has served on the scientific advisory board of and as a consultant for Baxter, CSL Behring, and UCB, Inc, and has served on the editorial board of Muscle & Nerve.

Unlabeled Use of Products/Investigational Use Disclosure: Drs Cohen and Donofrio report no disclosures.

INTRODUCTION

Current Procedural Terminology (CPT) is a publication of the American Medical Association, which is updated yearly, and lists all the five-digit codes and definitions for all Evaluation and Management (E/M) codes and procedural codes used to care for patients.1 The E/M codes make up a small component of CPT and are the codes that are used in delivering cognitive services. Specifically, the majority of E/M coding used by doctors who care for patients with dementia are ambulatory codes, which are used for the care delivered in the office setting. In general, the E/M codes require no special technology. In addition to the new and established office visit codes, some new CPT codes are available that are relevant to providers caring for patients with dementia.

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is the classification for medical coding supported by the Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics.2 The ICD-10-CM is the United States modification of the tenth revision of the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (whose short-form name is International Classification of Diseases, Tenth Revision [ICD-10]), and replaced the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) on October 1, 2015.2,3 Chapter 6 of the ICD-10-CM contains the codes for diseases of the nervous system (codes G00 to G99), with the Alzheimer disease codes contained in the G30 grouping. The G31 grouping contains “Other degenerative diseases of nervous system, not elsewhere classified,” and the G32 group contains “Other degenerative disorders of nervous system in diseases classified elsewhere.” The G30 and G31 codes will be used most often when coding for illnesses related to dementia. Refer to Coding Table 1 for a list of useful codes in this category.

Caring for patients with dementia provides a considerable clinical challenge that directly impacts all the most complex aspects of both the ICD-10-CM and CPT code sets. Initial evaluation requires an extensive review of any comorbid conditions, medical conditions that can mimic or contribute to dementia, and the medical and neuropsychological evaluation that is necessary to establish the correct diagnosis. Subsequent visits are complicated by discussions regarding disease progression and possible therapy to treat cognitive or behavioral manifestations, skilled nursing care, palliative care, and end-of-life planning. The patient is often attended by an elderly spouse who may also have medical or cognitive issues, leading to visits lasting longer than what has been scheduled. Patients with dementia are usually insured by Medicare, which tends to be reimbursed at a lower rate than commercial insurance, so any practice with a large number of patients with dementia cannot function under the same budgetary constraints as with other practices. In general, caring for patients with dementia does not require procedural technology that tends to be reimbursed at a higher level. Because of all these factors, the providers that care for patients with dementia face a difficult challenge for financial solvency. This means that providers caring for patients with this illness must be accurate with their coding in order to charge properly for services delivered and not have claims rejected because of erroneous coding practices.

DISCUSSION

Although the physician suspects Alzheimer disease, because no specific diagnosis can be determined at this time, the G30 codes (representing the various Alzheimer disease codes) are probably not the best choice to use when coding for this patient. When dementia is known but the etiology is not, the ICD-10-CM code best used in this case is F03.90.

F03.90 Unspecified dementia without behavioral disturbance

Refer to Coding Table 1 for a list of related codes. Case 1 did not state if the patient’s visit was with her primary care provider or if she was being seen for the first time by a new provider or by a specialist, functioning as a consultant. If this patient’s visit was with her primary care provider, the best CPT code choice would be 99215, a level 5 established patient visit. If the visit were coded based on “bullets,” the comprehensive medical history and comprehensive physical examination, using the 1997 neurologic single system examination, would default this visit to the highest level of intensity.4 Furthermore, the medical decision making involves a life-altering diagnosis, a visit type of the highest risk, and would be viewed again as the highest level of intensity. Although this visit was 60 minutes in duration, if the provider performed the same elements in 30 minutes (less than the typical 40 minutes assigned to this visit), the 99215 code would still be justified on the basis of the work performed and documented. If the visit were to be coded based on counseling and/or coordination of care, also referred to as time-based billing, the visit would also be coded as a 99215 because over 50% of the total time of the visit was spent educating the patient and family about the illness. If counseling and coordination of care is chosen for the 99215 code, the visit must be a minimum of 40 minutes, with greater than 50% of the time spent performing counseling and coordination of care issues. In this case, the visit duration was 60 minutes, 35 of which were spent performing this task. There is no code available for a visit that runs 20 minutes longer than specified by CPT, and the physician does not receive extra reimbursement for this time.

If the physician had not provided care to that patient in over 3 years, such as a consulting neurologist, CMS would consider this a new patient visit. Although consult codes (99241 to 99245) remain a part of CPT, in 2010 CMS stopped paying for these codes for Medicare patients, so this patient would need to be billed as a new patient using the codes 99201 to 99205. Many commercial carriers and some Medicaid carriers do accept the consult codes, so if the patient was referred for a consultation, those codes could be applied. Sixty minutes is the typical time spent to complete elements for a 99205 code and also is the minimum time required if counseling and coordination of care are used to support time-based billing. For the same reasons given for the previous discussion about the established patient, this patient’s office visit would qualify for a 99205 code, the highest level in the ambulatory new patient codes (60-minute visit with a 25-point comprehensive history and examination and complex medical decision making or 35 minutes spent counseling and coordinating care).

Case 1

A 67-year-old woman presented because of memory difficulties. The family relayed memory and behavior problems, specifying “there are good days and bad days.” One year before presentation she had gotten lost on her way home, and the patient had stopped driving except to go to work, the bank, and the grocery store. Over the prior months her children noticed their mother’s usual animated and lengthy conversations become brief and lack emotion. She had spent her life working as a bookkeeper for the family’s dry cleaning business, and employees had recently noted errors in their paychecks. Her past medical history was notable for hypothyroidism, hypercholesterolemia, type 2 diabetes mellitus, and a painful neuropathy attributed to her diabetes mellitus, which was treated with levothyroxine, simvastatin, metformin, and gabapentin. Her family history was unremarkable. The remainder of a 10-organ review of systems was negative. Her heart rate, blood pressure, and temperature were normal. The general physical examination, including cardiovascular elements, was normal. Her speech was slow with loss of normal prosody but there were no paraphasic errors. She was able to name most objects, and her memory was two out of three at 5 minutes. Her general fund of information for history and jazz music (her passion) was normal but she was not able to name the current president, the governor of her state, or its capitol citing “congress controls our government anyway.” Her Mini-Mental State Examination (MMSE) score was 25 out of 30 points, with the patient appearing to be fully engaged in the task. The remainder of the 25-element neurologic examination was normal. There were no historical elements to suggest depression. The physician informed the patient and her family that her memory problems could at best be the result of an underlying “fixable” medical condition such as a vitamin deficiency or a slow-growing benign brain tumor, or the problem could be the result of a dementing condition such as the early stages of Alzheimer disease. The physician wanted to order tests and then decide about further plans. The duration of the visit was 60 minutes, and the physician spent 25 minutes performing the history and examination, with the remaining 35 minutes discussing the differential diagnosis of mild cognitive impairment.

Case 1 Continued

After her initial visit, where several tests had been ordered, the patient returned for a follow-up visit to discuss the results and further considerations for care. The thyroid-stimulating hormone (TSH), vitamin B12 levels, hemoglobin A1c, and cholesterol were normal. A brain MRI showed only mild volume loss. No additional symptoms were reported. The only examination performed during the patient’s second visit was a cursory cardiac examination and the observation of the patient’s affect and language function. The patient and family declined further evaluation. Following a brief discussion, the physician told the family the diagnosis was likely mild late-onset Alzheimer disease, suggested treatment with rivastigmine, and scheduled a return visit in 3 months. The visit duration was 15 minutes and the physician spent 10 minutes performing counseling for the diagnosis and management. Following the physician leaving the office, the registered nurse spent 20 minutes going over the medication and side effects with the family and offered advice and comfort.

Case 1 Continued

The patient continued to be followed with biannual appointments. During the last few years, her memory and language function deteriorated, and she stopped working. Although she was safe at home and participated in family events, she could no longer cook or plan family events. She had a myocardial infarction following surgery for noninvasive bladder cancer. The patient reiterated to her husband over the years that she did not want any “heroics” or be “hooked up to tubes” if she became ill. The husband felt that the physician who cared for her and made her diagnosis of Alzheimer disease was best able to talk to his wife, to direct them to the right choices, and possibly even fill out the forms. At her tenth follow-up visit, the patient was accompanied by her husband and daughter. The total duration of the visit was 50 minutes, and during that time the physician assessed the patient to be competent to make these decisions, and with no objection from family members, paperwork for end-of-life planning, including health care power of attorney and advance directives, were completed and signed. No physical examination was performed outside the questions asked to assess competency.

DISCUSSION

Because the physician diagnosed Alzheimer disease, the best code choices are the following from ICD-10-CM:

G30.1 Alzheimer disease with late onset

F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance

By definition, late onset is used for those with symptom onset after age 65. If the symptom onset was before age 65, then G30.0 (Alzheimer disease with early onset) would be the best choice. All dementia etiology codes require a second manifestation code from Chapter 5 of ICD-10-CM, describing dementia with or without behavioral disturbance. Because this was an established ambulatory visit, the CPT code set would be the 99211 to 99215 codes. Despite the gravity of the diagnosis, only a problem-focused history was obtained along with a focused examination. This was justified as the choice of the extent of history and physical examination is at the discretion of the physician performing the service and should be commensurate with the nature of the chief complaint and presenting problem. The physician should not perform an overly extensive history or examination just to “up-code,” and the choice on the second visit not to perform a more extensive history or physical examination was justified. In this case, the extent of both the history and physical examination were by definition, “problem focused,” the lowest level available. The medical decision making is composed of three elements: number of diagnostic and management options, data review, and risk of morbidity and mortality. Although the determination of any of these elements is subjective, one could argue there were limited diagnostic and therapeutic decisions during this office visit, the data complexity was moderate, and the risk of morbidity and mortality was high. The rule is that the lower of the highest two levels determines the overall level of medical decision making, which, in this case, would be moderate. Determining the correct code for this case is challenging and likely would be CPT code 99213 based on bullets and level of medical decision making.

99213 Office or other outpatient visit for the evaluation and management of an established

Given the majority of this visit was spent providing counseling to the patient, a 99213 code could be justified based on this time (15-minute visit with 10 minutes spent in counseling and coordination of care). Although the registered nurse spent a considerable amount of time with the family, time spent by any nursing services (registered nurse or licensed practical nurse) or office staff cannot be used by the provider in selecting a level of service for office-based E/M codes.

In this case the ICD-10-CM code choices would remain the same:

G30.1 Alzheimer’s disease with late onset

F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance

The proper CPT code(s) would be 99497 and 99499.

99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.

DISCUSSION

In this case the ICD-10-CM code choices would remain the same:

The proper CPT code(s) would be 99497 and 99499.

The 99499 code is an add-on code to the 99497 when another 30 minutes of time is spent after the initial 30 minutes spent for the 99497 code. Because more than one-half of the 30 minutes was spent (in this case, 20 minutes past the 30 minutes required for the initial code), the 99499 code is allowed.

DISCUSSION

The Mini-Mental State Examination (MMSE) is considered part of a standard neurologic examination and cannot be used to justify the CPT 96118 code (neuropsychological testing). When a physician or psychologist performs face-to-face neuropsychological testing that goes beyond the informal testing (such as the MMSE) done as part of the neurologic examination, the code 96118 can be used. This is a code that is time based, and one unit of 96118 can be billed for test administration, review of computerized testing, and report preparation by the physician or psychologist. This can also be used to interpret and report on testing done by technicians or by computer. In this case, two units of service were performed and, therefore, 96118 × 2 can be billed.

Memory Scales, and Wisconsin Card Sorting Test), per hour of the psychologist’s or physician’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.

Case 2

The patient’s initial presentation was similar to Case 1, except the symptoms and neurologic signs were milder. The Mini-Mental State Examination (MMSE) score was 26 out of 30. In addition to all the testing performed in Case 1, the neurologist asked that the patient be evaluated by a geriatric psychologist for the purpose of investigating the possibility of depression. That evaluation was performed and the patient had no evidence of a mood disturbance or other psychiatric illness. The neurologist, who had expertise in neuropsychological testing, asked the patient to come to the office for the purpose of performing additional cognitive testing. At that visit, 1 hour of standardized cognitive, memory, and language testing was performed, and the report preparation time was 1 additional hour. This testing determined that the patient likely was experiencing the early signs of dementia.

DISCUSSION

Because the etiology of the dementia is not known, the ICD-10-CM code F03.91 is the most appropriate to use for this patient.

F03.91 Unspecified dementia with behavioral disturbance

The other neurologic findings, including the shuffling gait, hyperreflexia in the arms, and absent reflexes in the legs, represent findings that could be used to justify additional medical testing, so the other code choice that would be reasonable could include ICD-10-CM code R26.89.

R26.89 Other abnormalities of gait and mobility

The best choice for the E/M code would be established CPT care code 99214, as the history and examination are high complexity and the medical decision making is moderately high complexity. The physician could bill the same code if 35 minutes were spent with the patient and more than 50% was expended in counseling and coordination of care.

99214 Office or other outpatient visit for the evaluation and management of an established

Case 3

An 89-year-old woman with a history of mild congestive heart failure and anxiety, treated with digoxin and clonazepam, presented with a several-week history of worsening anxiety as well as frequent awakenings at night with behavioral disturbances. She lived with her great nephew and, until recently, was able to prepare meals, clean the house, and care for all of her activities of daily living. Her family reported that she was now commonly confused about dates, time, and facts about current events. Past history, social history, medications, family history, and a 10-system review of systems was performed. A full physical examination was performed and documented. On examination, the patient recalled of two out of three words at 5 minutes. Her speech content was generally normal, although there were times when she was mumbling words and phrases that were not understandable. She did not know the day of the week, day of the month, her wedding anniversary, or the name of her deceased husband. The general physical examination was normal aside from a kyphotic posture that has been present for at least 20 years. She had mild shuffling gait, also long standing, but no tremor or bradykinesia. Deep tendon reflexes were increased in the arms and at the knees and absent at the ankles. Toes were extensor on plantar stimulation. Sensation to vibration was reduced at the toes and ankles. At the conclusion of this visit, the physician thought her illness was consistent with a dementia but wanted to order tests to make sure there were no treatable conditions or conditions that would require a decision about how to move forward with her medical and social care, such as a malignant brain tumor. The duration of this office visit was 35 minutes.

Case 3 Continued

A brain MRI showed moderate cerebral atrophy and microvascular disease changes. The thyroid-stimulating hormone (TSH) and free T4 were normal. The complete blood cell count showed a hemoglobin of 8.9 g/dL (normal range is 12 mg/dL to 15 mg/dL) and the mean cell volume was elevated at 110 fL (normal range 80 fL to 100 fL). The vitamin B12 level was low at 176 pg/mL (normal range 200 pg/mL to 900 pg/mL) and the methylmalonic acid level was elevated at 2.1 mmol/L (normal range 0.08 to 0.56 mmol/L). The physician reviewed these laboratory tests and decided the proper management would be institution of vitamin B12 injections. The physician saw the patient a few days later. An examination was not performed. He told the patient and her family the “good news” that she had a potentially treatable dementia, and relayed that the treatment may or may not be effective considering her age and how long the vitamin B12 deficiency may have been present. The physician increased the clonazepam dose to 0.25 mg 3 times per day and instructed the patient to come in monthly for a vitamin B12 shot, after a loading dose of weekly vitamin B12 for several weeks. The total face-to-face time with the patient was 20 minutes. The patient remained in the examination room after the doctor left and the nurse came in moments later to give the patient her first IM injection of cyanocobalamin and spent 15 minutes with the family going over information on fact sheets about pernicious anemia.

Case 3 Continued

The patient returned 2 months later for a monthly vitamin B12 injection, scheduled as a nurse-only visit. The family told the nurse the episodes of confusion were improved after the loading doses of vitamin B12 and they stopped the clonazepam (on their own volition) aside from her prior bedtime dose. Before the vitamin B12 was administered at the visit, the nurse stepped out of the examination room and pulled the doctor aside to give him the good news. The doctor replied, “Great, let’s keep giving her the vitamin B12.” The nurse went back into the room and gave the patient another vitamin B12 injection and scheduled the patient to return in a month for another injection.

The E/M CPT coding for this visit would be 99213 as the total face time was 20 minutes, all of which was spent in counseling and coordination of care. There is no means to code for the nurse’s time as it is provided on the same day as the visit to the primary care doctor.

CONCLUSION

Caring for patients with cognitive problems is heavily weighted toward E/M services and is additionally challenging because the illness itself requires extra time to provide these services. The use of time-based billing is often the best way for the provider to properly bill for their services and, therefore, the provider should be well-versed on these requirements. The proper ICD-10-CM code may change between visits, especially as the etiology of the illness is identified. The underlying cause of the dementia (or other associated conditions), once identified, should be listed first, with the sequelae, including dementia, following.